• Peri-operative antibacterial prophylaxis in urology. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P. Guidelines on the management of urinary and male genital tract infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2008 Mar. p. 90-9. [39 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Conditions in which peri-operative antibacterial prophylaxis could prevent infective complications resulting from diagnostic and therapeutic procedures, such as:

• Transrectal biopsy of the prostate (TURP)
• Cystoscopy
• Urodynamic examination ureteroscopy
• Extracorporeal shockwave lithotripsy (ESWL)
• Transurethral resection of the prostate or of a bladder tumour
• Open urologic surgery (including implantation of prosthetic device)

Prevention
Risk Assessment

Infectious Diseases
Nephrology
Preventive Medicine
Surgery
Urology

Physician Assistants
Physicians

• To assist urologists and physicians from other medical specialties in their daily practice
• To provide recommendations on peri-operative antibacterial prophylaxis in urological surgery
• To clarify the current state of knowledge and to propose practical recommendations based on clinical studies, expert opinions, and professional consensus

Patients at risk for peri-operative urologic infection

1. Categorization of patients according to risk for infection
2. Urine culture prior to surgery
3. Consideration of principles of antibiotic prophylaxis including:
   • Timing
   • Route of administration
   • Duration of regimen
   • Choice of antibiotics
4. Use of antibiotic prophylaxis according to type of procedure and risk
   • Fluoroquinolones
   • Trimethoprim-sulfamethoxazole (TMP-SMZ)
   • Second- or third-generation cephalosporins
   • Aminopenicillin/beta-lactamase inhibitor
   • Penicillin
   • Metronidazole

• Risk of peri-operative infection
• Relative risk reduction for bacteriuria and septicemia
• Rate of antimicrobial resistance

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

General Search Strategy

Up until 2007, the main strategy was to rely on the guidelines group members' knowledge and expertise on the current literature assuming that all, or almost all, relevant information would be captured.

In updates produced from 2008 onwards, a structured literature search will be performed for all guidelines but this search will be limited to randomized controlled trials and meta-analyses, covering at least the past three years, or up until the date of the latest text update if this exceeds the three-year period. Other excellent sources to include are other high-level evidence, Cochrane review and available high-quality guidelines produced by other expert groups or organizations. If there are no high-level data available, the only option is to include lower-level data. The choice of literature will be guided by the expertise and knowledge of the Guidelines Working Group.

Specific Strategy for This Guideline

For literature review, PubMed was searched for published meta-analyses, which were used as far as available. Otherwise there was a non-structured literature review process by the group members. Each member was responsible for one chapter (reporter).

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Ia Evidence obtained from meta-analysis of randomized trials

Ib Evidence obtained from at least one randomized trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study

III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus (Consensus Development Conference)

General Methods Used to Formulate the Recommendations

• The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
• The second step is to establish a working group. The working groups comprise about 4-8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields (radiotherapy, oncology, gynaecology, anaesthesiology etc.) are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
• The third step is to collect and evaluate the underlying evidence from the published literature.
• The fourth step is to structure and present the information. All main recommendations are summarized in boxes and the strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

Specific Methods Used for This Guideline

The members of the Urinary Tract Infection (UTI) Working Group of the European Association of Urologists (EAU) Health Care Office established the first version of these guidelines in several consensus conferences. The members of the current UTI Working Group of the EAU Guidelines Office updated the guidelines in several consensus conferences thereafter. The first draft of each chapter was sent to the committee members asking for comments, which were then considered, discussed and incorporated accordingly.

Grades of Recommendation

1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
2. Based on well-conducted clinical studies, but without randomized clinical studies
3. Made despite the absence of directly applicable clinical studies of good quality

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The following is a summary of the recommendations for peri-operative antibacterial prophylaxis in urology. Refer to the original guideline for more detailed recommendations and discussion.

The aim of antimicrobial prophylaxis in urological surgery is to prevent infective complications resulting from diagnostic and therapeutic procedures. However, the evidence on the best choice of antibiotics and prophylactic regimens is limited.

There is no evidence for any benefits of antibiotic prophylaxis in standard non-complicated endoscopic procedures and extracorporeal shockwave lithotripsy (ESWL), though it is recommended in complicated procedures and patients with identified risk factors.

For open surgery, the same rules as in abdominal surgery can be applied. No antibiotic prophylaxis is required for clean operations, while a single or 1-day dosage is recommended in clean-contaminated operations. Opening of the urinary tract should be considered as clean-contaminated surgery.

It is essential to categorize patients according to risk factors for infection. These include:

• History of genitourinary infection
• Previous instrumentation
• Assumed bacterial colonization
• Prolonged hospital or institutional stay
• Risk factors related to general health (e.g., diabetes mellitus, impaired immune system, malnutrition)

A single dose or a short course of antimicrobials can be given, either parenterally or orally. The administration route will depend on the type of intervention and patient characteristics. Oral administration requires drugs having good bioavailability. In a case of continuous urinary drainage, prolongation of peri-operative antibiotic prophylaxis is not recommended.

Many antibiotics are suitable for peri-operative antibacterial prophylaxis (e.g., second-generation cephalosporins, co-trimoxazole-sulphamethoxazole [TMP-SMZ], fluoroquinolones, aminopenicillins plus a beta-lactam inhibitor [BLI], and aminoglycosides). Broader-spectrum antibiotics should be used sparingly and reserved for treatment. This applies also to the use of vancomycin.

The use of antimicrobials should be based on knowledge of the local pathogen profile and antibiotic susceptibility pattern. Best practice includes surveillance and an audit of infectious complications.

Table: Recommendations for Antibiotic Prophylaxis in Standard Urological Surgery

BLI = beta-lactamase inhibitor; ESWL = extracorporeal shockwave lithotripsy; TMP ± SMX = trimethoprim with or without sulphamethoxazole (co-trimoxazole); TUR = transurethral resection

None provided

The type of evidence supporting the recommendations is not specifically stated.

Prevention of urological infection

Not stated

• The purpose of these texts is not to be proscriptive in the way a clinician should treat a patient but rather to provide access to the best contemporaneous consensus view on the most appropriate management currently available. European Association for Urology (EAU) guidelines are not meant to be legal documents but are produced with the ultimate aim to help urologists with their day-to-day practice.
• The EAU believe that producing validated best practice in the field of urology is a very powerful and efficient tool in improving patient care. It is, however, the expertise of the clinician which should determine the needs of their patients. Individual patients may require individualized approaches which take into account all circumstances and treatment decisions often have to be made on a case-by-case basis.

Staying Healthy

Effectiveness

• Peri-operative antibacterial prophylaxis in urology. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P. Guidelines on the management of urinary and male genital tract infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2008 Mar. p. 90-9. [39 references]

Not applicable: The guideline was not adapted from another source.

2008 Mar

European Association of Urology - Medical Specialty Society

European Association of Urology

Management of Urinary and Male Genital Tract Infections Guidelines Writing Panel

Panel Members: M. Grabe (Chairman); M.C. Bishop; T.E. Bjerklund-Johansen; H. Botto; M. Çek; B. Lobel; K.G. Naber; J. Palou; P. Tenke

All members of the Management of Urinary and Male Genital Tract Infections guidelines writing panel have provided disclosure statements of all relationships which they have and which may be perceived as a potential source of conflict of interest. This information is kept on file in the European Association of Urology Central Office database. This guidelines document was developed with the financial support of the European Association of Urology (EAU). No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance, travel, and meeting expenses. No honoraria or other reimbursements have been provided.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

The following are available:

• EAU guidelines office template. Arnhem, The Netherlands: European Association of Urology (EAU); 2007. 4 p.
• The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology (EAU); 18 p.

The following is also available:

• Management of urinary and male genital tract infections. 2008, Ultra short pocket guidelines. Arnhem, The Netherlands: European Association of Urology (EAU); 2008 Mar. 17 p.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

None available

This NGC summary was completed by ECRI Institute on September 9, 2008. The information was verified by the guideline developer on December 8, 2008.

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.